Microsoft word - ct requisition 2009

Name: ______________________________________________ CT REQUISITION
PIN#: _______________________________________________ DOB: _______________________________________________ University Hospital Victoria Hospital
Bookings Central Bookings
HC#: _______________________________________________ Telephone: 519-663-3212 Telephone: 519-685-8770 Address: ____________________________________________ Phone: _____________________________________________ PHYSICIAN INFORMATION:
Print Name (with initials):__________________________________ SIGNATURE:→_________________________________________ Date of Injury:__________________________
Address:_______________________________________________
______________________________________________________ _____________________________________
Telephone:___________________ Fax:_____________________
INPATIENT OUTPATIENT 3rd PARTY / INSURANCE Examination Requested: ___________________________________________________________________________________
Clinical Problem: (must be entered)___________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
All of the following questions must be completed before the CT will be booked.
1. Is the patient allergic to radiographic IV contrast? 2. (a) Is there a history of renal impairment or nephrectomy? (b) Is the patient currently on dialysis? (d) Is the patient on any medication for diabetes? If yes, do they take medication called Metformin, Glucophage or Avandamet? (e) Does the patient have other medical conditions or take any medications that may Please list: ________________________________________________________ If you answered yes to any of the items in Question 2 and your patient requires/or may require
IV contrast, a recent creatinine (<2 months) must be forwarded with the requisition.
Creatinine: ____________________________ Date (YYYY/MM/DD): ____________________________
3. Given the patients history and as advised in the product monograph for Yes Omnipaque 300, would you recommend the use of contrast if required? 4. Patient weight: ________________lb/kg? 5. Is there a history of pheochromocytoma, multiples myeloma, heart disease or other? Please list:_________________________________________________________________________________________ 6. Are you requesting a timed follow-up procedure (eg. 6 month follow-up)?
If yes, date requested (YYYY/MM/DD):_______________________________________
If no, how would you rate the urgency or relative priority of this patient: (circle one)
10 9 8 7 6 5 4 3 2 1
Not Urgent At All Extremely Urgent
CT Exam Date (YYYY/MM/DD): _________________________________________________
-- RADIOLOGY USE ONLY--
Booking Priority:
Protocol:
1 Emergency <12 hr 4 Non Urgent
2 Urgent 4T Non Urgent/Timed
2T Urgent/Timed
3 Semi Urgent
3T Semi Urgent/Timed

Source: http://www.mriappointments.com/forms/genreqlh.pdf